Andrei Rosaa; Natalino Francisco da Silvaa; Alex Semenoff Segundob; Tereza Delle Vedove Semenoffc; Alvaro Henrique Borges*a; Alexandre Meireles Borbaa
Abstract
Individuals with chronic renal failure (CRD) undergo hemodialysis to compensate for systemic-based disease and often develop systemic arterial hypertension (SAH). Such individuals, when needing dental treatment, carry with them the consideration of which type of anesthetic to be used in clinical and surgical interventions. The objective of this study was to evaluate the action of anesthetics with vasoconstrictor (AwV) and without vasoconstrictor (AoV) in individuals with chronic renal failure. Research subjects needed dental treatment, with dental restorations, on the right and left lower dental arch in premolars and / or molars, thus receiving the model of a split-mouth clinical study. In a randomized study, each side of the mandible was subjected to an anesthetic infiltration with only one 1.8 mL tube in two different moments with a minimum interval of 7 days (for one moment with AwV and another AoV moment). The parameters of oxygen saturation (SaO2), heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured 5 minutes before anesthesia, 5, 15 and 30 minutes after anesthesia. The results found in this study showed statistical difference only in SaO2 in the time of 5 minutes after the anesthesia in comparison of the AwV and AoV group, this same result was obtained when only those individuals who, besides nephropathies, had a diagnosis of SAH, were evaluated. The findings of this study highlight the safety of the use of anesthetics, with or without vasoconstrictors since in small amounts, in individuals with CRF with or without associated SAH.
Keywords: Renal Insufficiency. Hypertension. Anesthetics, Local. Resumo
Indivíduos com insuficiência renal crônica (IRC) em geral são submetidos à hemodiálise para compensação da doença de base sistêmica e frequentemente desenvolvem a hipertensão arterial sistêmica (HAS). Tais indivíduos, ao necessitarem de tratamento odontológico, levam consigo a ponderação de qual tipo de anestésico a ser utilizado em intervenções clínicas e cirúrgicas. O objetivo deste estudo foi avaliar a ação de anestésicos com vasoconstritor (ACV) e sem vasoconstritor (ASV) em indivíduos com insuficiência renal crônica. Os indivíduos da pesquisa tinham necessidade de tratamento odontológico, com restaurações dentárias, no arco dentário inferior direito e esquerdo em pré-molares e/ ou molares, recebendo assim o modelo de estudo clínico de boca dividida. De forma aleatória, os hemiarcos inferiores foram submetidos, em dois diferentes momentos com intervalo mínimo de 7 dias, a infiltração anestésica com apenas um tubete de 1,8 mL (para um momento com ACV e outro momento ASV). Foi feita aferição dos parâmetros de saturação de oxigênio (SaO2), frequência cardíaca (FC), pressão arterial sistólica (PAS) e diastólicas (PAD), 5 minutos antes da anestesia, 5, 15 e 30 minutos após a anestesia. Os resultados encontrados neste estudo demonstraram diferença estatística apenas na SaO2 no tempo de 5 minutos após a anestesia em comparação do grupo ACV e ASV, esse mesmo resultado foi obtido quando avaliados apenas os indivíduos que, além de nefropatas, apresentavam diagnóstico de HAS. Os achados deste estudo ressaltam a segurança do uso de anestésicos, com ou sem vasoconstritores desde que em pequenas quantidades, em indivíduos com IRC com ou sem HAS associada.
Palavras-chave: Insuficiência Renal. Hipertensão. Anestésicos Locais.
The Influence of Vasoconstritor Use in Local Anesthesia in Individuals with Chronic Renal
Failure
A Influência do Uso de Vasoconstritor na Anestesia Local em Indivíduos com Insuficiência
Renal Crônica
aUniversity of Cuiabá, Stricto Sensu Graduate Program in Integrated Dental Sciences. MT, Brazil. E-mail: College of Sinop. bCollege Applied Social Sciences of Vale do São Lourenço. MT, Brazil.
cPrivate Dental’s Office MT, Brazil.
*E-mail: alvaro.borges@kroton.com.br Recebido em: 04/02/19 Aprovado em: 02/08/19
1 Introduction
Chronic renal failure (CRF) has been considered a public health problem, affecting more than 7% of the world population, from 20 to 59 years1.2 The renal disease is classified in
accordance with the stages of severity of glomerular filtration rate (TGF). The IRC is the most advanced stage of the disease and consists of the gradual, irreversible and multifactorial loss of renal, urinary and endocrine function to maintain the metabolic and hydro electrolytic balance, generating changes in various body systems3.
The IRC leads to systemic problems such as DM and hypertension and this association can lead to other systemic problems that lead to the worsening of the individual. Hypertension is the most prevalent comorbidity among the diseases developed in HD treatment for individuals with this IRC,4-7. Individuals with CRF need health care, avoiding
infectious processes and which may compromise their homeostasis, especially in individuals who undergo surgery for renal transplantation8.
Severe systemic diseases, such as kidney diseases, are risk factors for injury or tooth loss, in this sense, the oral
cavity in this group of patients has received great attention by professionals who deal with the IRC, especially individuals who undergo hemodialysis (HD), because the infections present at this location can affect the whole body9. Individuals
with CRF should make dental monitoring for treating or preventing oral health problems as carious lesions, periodontal disease and tooth loss10.11 for this, it is crucial the assiduity to
the dentist for control of oral microbiota12.
Individuals with CRF often have SAH, which determines a more careful choice of anesthetics to be used2,5-7. Due to the
need of dental care, the dental surgeon, requires the use of local anesthetics for the realization of various procedures the choice of anesthetic to be used should consider the anesthetic potency, latency (time of onset of anesthesia), duration of the anesthetic effect, the pharmacokinetics (absorption, distribution, metabolism and excretion) and toxicity13. The
anesthetic injection associated with the use of vasoconstrictors in dentistry can lead to changes in diastolic blood pressure (DBP) and systolic blood pressure (SBP) between the period before anesthetic induction and the stabilization period14.
The injection of anesthetics with vasoconstrictors may cause significant increase of BP, this way one must be cautious to administer this anesthetic combination to cardiovascular individuals14. Knowing that local anesthetics cause systemic
effects and due to lack of information related to these effects after anesthetic injection site in the group of individuals with CRF who commonly has the SAH associated, it is advisable to conduct studies to assess the effects caused by these substances. Therefore, it is proposed retrospective measurement of multi-parameter repercussion of local anesthesia, associated or not to vasoconstrictor, in individuals with CRF.
2 Material and Methods
This study translates into a clinical trial in a model of mouth divided carried out at University of (UNIC) between March 2017 and January 2018. The research participants were characterized by individuals with CRF undergoing treatment for HD by Renal Treatment Clinic - CTR (Cuiabá - MT), referenced to dental care dental clinic of the College of Dentistry of UNIC. This study is part of a research project approved by the Committee for Ethics in Research of the UNIC under record No. 21 CEP/UNIC - protocol 2011-021.
Inclusion criteria were listed as nephropathic patients diagnosed in stage 5 (renal failure requiring dialysis or transplantation for survival, with TGF estimated <15 mL/ min per 1.73), in HD for more than six months, aged over 18 years who needed dental intervention for dental restorations or exchange of simple cavity restorations in pre-molars or lower molars. Exclusion criteria were determined by systemic instability that did not allow dental insurance, the non-acceptance to dental treatment proposed, or the need to use more than one anesthetic cartridge (volume of 1.8 mL per cartridge) for intervention. Eligible individuals were grouped
in group IRC. IRC group individuals with concomitant diagnosis of SAH, were secondarily subdivided in IRC group with SAH.
The dental diagnosis was done by means of physical examination and radiographic testing of pulp vitality in the teeth to be treated. The service was done in two visits, following the model of split mouth, being performed the anesthesia of the IAN block technique to perform the procedure necessary in each one of the sessions.
The technique used for the IAN block was the direct block, initially performed by the identification of the lines formed by the ascending branch and the pterygomandibular ligament and outlining the bisection of the angle of these lines; the carpule syringe was positioned between the pre-molars on the side opposite one centimeter above the occlusal plan with the bevel of the needle facing the inner face of the branch of the mandible and starting the puncture as it penetrates into the tissue to insert the needle until this touched the bone. Then, the needle was backed one centimeter, and it was observed the absence of blood reflux, and the remainder of the anesthetic was injected15.
As outcome variable, two different types of anesthetics were used, one for each intervention. The group of local anesthetics with vasoconstrictor (ACV) was determined using 2% mepivacaine with epinephrine 1:100,000 (MEPIADRE, mepivacaine hydrochloride 36mg + epinephrine 18 ug) while the group of anesthetics without vasoconstrictor (ASV) 3% mepivacaine was used without vasoconstrictor (MEPIASV, mepivacaine hydrochloride 54mg/ without vasoconstrictor).
The hemi-arch choice to be treated first, and the anesthetic to be used in each session (group ACV or ASV) was performed by means of a draw with a coin, promoted by the same assistant who was responsible for the data collection and by masking the operator knowledge in relation to the anesthetic to be used. This masking was done using gloves for carpule syringe, delivered to the researcher already prepared with the anesthetic and with long needle. In the second session of each individual, the antagonist side was worked and it was used another anesthetic, even without the knowledge of both the individual and the operator.
Prior to and during both interventions, the parameters for SBP and DBP were measured with the digital arm automatic pressure apparatusML303 G-TECH being observed to assess the individual’s arm with IRC where there was not the arteriovenous fistula used to HD. Also, the heart rate (HR) and arterial oxygen saturation of hemoglobin (SaO2) were evaluated with the finger oximeter (G-TECH). All parameters were recorded, with the aid of a stopwatch, in times of 0, 5, 15 and 30 minutes after anesthetic injection.
At each of the sessions prior to the anesthetic technique an initial rating was performed (T0) of SBP, DBP, HR and SaO2, followed then with the anesthetic technique and after 5 minutes a new measurement was performed (T5), 15 and 30
minutes after the anesthetic technique, it was measured again (T15 and T30).
Carious lesion or unsatisfactory restoration was removed, and the new dental restoration was performed using composite resin (Z250 - 3M). The subjects requiring more invasive treatment such as endodontic treatment, tooth extractions, periodontal treatment, profound or very profound restorations, were forwarded to the project of care for chronic renal individuals but were not included in this assessment.
The data were collected and classified in a database in Excel for further statistical and descriptive analysis of the influence of the type of anesthetic in the parameters of SBP, DBP, HR, and SaO2, both for the IRC group and for the group IRC with SAH. The statistical analysis was performed by the QuickCalcs Software (GraphPad Software, La Jolla, CA, USA) using the paired t test.
3 Results and Discussion
Among the 23 eligible individuals to THE research, three were excluded for various reasons, finalizing the final sample with 20 individuals in group IRC. The average age of the sample was 47.85±9.76 years. It was observed that 75% (15) were men and only 1 (5%) individual made use of alcoholic beverage. In their majority, individuals were affected by hypertension 70% (14), comprising the subdivision of the group of CRF with SAH and DM 85% (17) (Table 1).
Table 1 - Epidemiological data of the sample.
Variable Group of individuals IRC
Gender CategoriesMale 15N 75%
Female 5 25
Alcoholic YesNo 191 955
SAH YesNo 146 7030
DM YesNo 173 8515
Age (in
years) Average 47.85 9.76± Minimum37 Maximum 72
CRF - Chronic Renal Failure; SAH- Systemic arterial hypertension-- diabetes mellitus; N - number of individuals; % - Percentage.
Source: Data from the survey.
The evaluation of the parameters of HR, SaO2, SBP and DBP in individuals with CRF compared to the presence or absence of vasoconstrictor in local anesthetics has resulted in statistical significance only to the variable SaO2 at time T5 of measurement, with an average of oxygenation increased when used local anesthetic with vasoconstrictor (Table 2).
Table 2 - Average and standard deviation for the variables of the study - IRC group (n=20).
Anesthetic
Significance
ACV ASV
Variable Average DP Average DP FC T0 75.90 11.25 75.10 12.18 0.7163 T5 76.55 11.50 75.50 13.06 0.5148 T15 75.60 11.73 74.85 11.17 0.7656 T30 76.35 11.93 74.40 11.64 0.3059 SaO2 T0 96.90 2.73 97.25 1.12 0.5822 T5 97.15 1.95 96.30 1.92 0.0433 T15 97.30 1.92 96.55 1.96 0.0917 T30 97.10 2.47 96.90 1.48 0.7157 PAS T0 140.90 28.33 133.85 29.15 0.1334 T5 144.50 29.20 135.05 28.39 0.0632 T15 142.05 27.11 135.40 27.10 0.0923 T30 144.60 29.32 137.15 25.78 0.0642 PAD T0 82.00 12.83 77.90 18.50 0.1145 T5 81.05 15.06 79.35 17.77 0.5639 T15 81.40 13.64 81.15 16.90 0.9292 T30 84.40 15.49 80.50 16.00 0.0672 ACV - local anesthetic with vasoconstrictor; ASV - anesthetic without vasoconstrictor; HR-Heart rate; SaO2 - oximetry; PAS - systolic blood
pressure; DBP - Diastolic Blood Pressure; SD - Standard Deviation; T0 - initial time, T5 - 5 minutes after anesthesia; T15 - 15 minutes after anesthesia; T30 - 30 minutes after anesthesia. Significance with P<0.05 by paired t test.
Source: Data from the survey.
When analyzing only the group of CRF with SAH, it was observed the same change in SaO2 (Table 3).
Table 3 - Average and standard deviation for the variables of the study - IRC group with hypertension (n=14).
Anesthetic
Significance
ACV ASV
Variable Average DP Average DP FC T0 73.29 11.08 73.93 13.28 0.7505 T5 73.71 11.31 72.50 12.98 0.5611 T15 73.00 11.40 74.14 12.47 0.6750 T30 73.93 11.89 72.64 11.66 0.3591 SaO2 T0 95.93 1.98 97.07 1.21 0.0877 T5 97.00 1.41 95.93 1.98 0.0417 T15 97.00 1.52 96.29 2.20 0.1365 T30 96.43 1.70 96.71 1.59 0.5830 PAS T0 144.07 23.26 132.50 21.22 0.0610 T5 142.71 25.35 134.86 22.60 0.2066 T15 143.71 23.50 134.50 23.51 0.0651 T30 144.14 26.29 135.93 21.90 0.1423 PAD T0 82.14 11.83 76.86 15.47 0.0932 T5 81.21 15.33 78.00 16.40 0.4079 T15 80.71 12.83 81.07 15.90 0.9176 T30 82.86 14.55 79.00 15.92 0.1579 ACV - local anesthetic with vasoconstrictor; ASV - anesthetic without vasoconstrictor; HR-Heart rate; SaO2 - oximetry; PAS - systolic blood pressure; DBP - Diastolic Blood Pressure; SD - Standard Deviation; T0 - initial time, T5 - 5 minutes after anesthesia; T15 - 15 minutes after anesthesia; T30 - 30 minutes after anesthesia. Significance with P<0.05 by paired t test.
the dental procedure proposed14.
Moreover, the present study demonstrates that possible variations in systemic parameters (SaO2, HR, SBP and DBP) may be associated with the pain of anesthetic injection30.
However, it is important to consider the limitation of this study by use of maximum 1 anesthetic cartridge (1.8ml), in respect to the literature data, which show that higher doses of local anesthetic with vasoconstrictor should be used sparingly14.
The findings of this study emphasize the safety of the use of anesthetics, with or without vasoconstrictors, as long as in small quantities, in individuals with CRF in hemodialysis treatment with or without SAH associated.
4 Conclusion
In this study it is concluded that the use of local anesthetics with or without vasoconstrictor showed no influence on SBP, DBP, HR and SaO2, to be administered by the proposed technique in individuals with CRF associated or not to SAH. References
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